How HMO Works -- The Referral Process

How HMO Works -- The Referral Process

Referrals are an important piece of saving money with your HMO coverage. It’s not enough to just have the HMO plan; you have to know when you need a referral and how to use your HMO plan. Did you know that with an HMO, unless it is an emergency, if you use a doctor or hospital that is not in your network you will be responsible for the full cost of the care provided?

What is a doctor referral?
A referral is authorization or permission from your Primary Care Physician (PCP) and health insurance provider to receive care from a specialist. A specialist is a doctor who treats specific conditions. Special treatment includes health care services from a specialist, hospital, or urgent care facility that cannot be provided by your PCP. You may also need a referral for things like lab work or physical therapy.

All specialist visits require your PCP to work with your health insurance provider for a referral. HMO plans cover some or all of the costs to see a specialist for covered services but only if you have the plan's permission before you see the specialist.

I have an HMO. How do I get a referral?

In order to receive health care services from a specialist you should:

  • Select a Primary Care Physician.
  • Visit your PCP to address your health care needs.

After the PCP has determined that you require care from a specialist, they will contact us – your health insurance provider – to approve the referral. After you are approved the PCP or Specialist will contact you to set up an appointment.

The specialist provides the services authorized by the referral only. If follow up care is needed, the specialist will need to get pre-authorization. If you need more services not included in the referral you’ll need another referral from your PCP.

If you are being treated for ongoing treatment, ask your PCP about a "standing referral". Your standing referral from your PCP will allow you to see your specialist without needing a new referral for each visit.

What is the PCP responsible for in the referral process?

The PCP will:

  • work with BCBSMT to authorize additional care that is beyond the first referral
  • refer you to an in-network medical specialist
  • monitor the care received from the specialist
  • work with BCBSMT to approve the referral
  • work with BCBSMT to issue referrals for lab work or physical therapy

When dealing with referrals always make sure:

  • your referrals are approved
  • your specialists are in-network
  • and your procedures have been authorized

To keep costs down, make sure all your health care services are either performed by or authorized by your PCP, and you use Provider Finder® to find a specialist in your network.

Get more information about your health plan at any time! Not all benefits are offered by all health plans. To see the limitations and exclusions in your plan, please refer to your benefit materials or log in or register for your member account, Blue Access for MembersSM. Visit the My Coverage tab to verify your coverage and identify your medical group and PCP.

Disclaimer: The information provided in this document is based on current information, should not be considered comprehensive and should not be relied upon for benefit decisions. It should not be considered legal or tax advice.